DxR – Ortho

本來以為隨便做做應該還ok, 沒想到我還是太嫩啦啦啦~~~ 結果, 零顆星… (奇怪, 我記得做完時有一顆星的啊! 不過沒差啦~ 幾顆不重要…) 以下是結果:

Diagnosis

Diagnosis:
The complete diagnosis for this patient includes vertebral compression fracture secondary to osteoporosis.

Your diagnosis:
lumbar compression fracture

did consider the correct diagnosis in your hypothesis list.

1. osteoporosis
2. pelvis fracture
3. bone tumor in sacrum
4. lumbar compression fracture

Osteoporosis is a condition in which the bone density is 2.5 standard deviations below the normal or average bone density of gender matched young adults. The term osteopenia refers to the less advanced stated of low bone mineral density and is a precursor to osteoporosis. The patient risk of fracture increases two to three times for every 10 percent drop in bone
density. Bone mass routinely declines after menopause and with increasing age making it a condition of elderly patients. The use of substances like tobacco, caffeine and steroids tend to decrease bone density as well.

Although both men and women show age-related decline in bone mineral density after age 40, most women have an accelerated phase of bone loss associated with the cessation of ovarian estrogen production in the 5 years after menopause. Men are protected against osteoporosis because they achieve higher peak bone mass and they do not have an abrupt fall in sex hormones.

Low bone density is the mechanism for most fractures and the lifetime risk for developing an osteoporotic fracture is approximately 50%. White women are at a higher risk followed by Asian women. Risk factors for the condition include white or Asian race, female sex, increased age, a mother or grandmother with a hip fracture, smoking, daily use of alcohol, poor
nutrition, small build, long term use of steroids, heparin, anticonvulsants and methotrexate, postmenopausal without the use of hormone replacement therapy and limited physical activity. The disease states of stroke, hyperthyroidism and Parkinson’s or diseases of memory impairment increase the risk as well.

Diagnosis is with the use of the dual electron x-ray absorptiometry (DEXA). Results are reported in terms of a T-score which compares the individual patient’s bone mineral density (BMD) with that of a young normal population and the z-scores which compare it with an age-matched control population. The World Health Organization defines osteoporosis as a T-score greater than 2.5 standard deviations below the young normal mean. Disadvantages to this technique are that bone density are not equivalent to bone strength and that adjacent calcium deposits may cause an artifactual increase in the reading.

Consider

★Present Illness|01 Why are you here today? What problems are you having?
　Medical History|05 Drugs, present medication, past medication, non-medical uses
　Medical History|08 Gynecologic history
★Medical History|06 Family medical history

The age and race of the patient, her postmenopausal status and lack of hormone replacement allow for the consideration of osteoporosis. Other risk factors for assessment in the patient history are smoking, caffeine and alcohol intake and a family history of osteoporosis in mother or grandmother. Lastly, the presentation of a fracture with a relative lack of serious trauma
would make you question the strength of the patient’s skeleton and the possibility of osteopenia. You might also question the possibility of domestic violence and search for other warning signs.

Justify

　Lifestyles|04 Diet
　Lifestyles|03 Caffeine
★Lifestyles|01 Alcohol
★Lifestyles|09 Tobacco
★Lifestyles|05 Exercise
★X-rays|26 Lumbar Spine (X-ray) (L spine, LS spine)
★X-rays|09 Bone Densitometry – Dexa-Scan Hip and Lumbar Spine

The bone density study is the gold standard for evaluation of osteopenia and osteoporosis, it is not required for diagnosis as both can be detected on radiograph. However, it is important in assessing the degree of loss and the effects of therapy. Remember if there are several fractures the telescoping effect of the fractures will cause the bone density to be greater than it
would ordinarily causing the device to over read the bone density. The presence of severe arthritis of the spine, or calcification of the ligaments or arteries around the spine will also artifactually raise the bone density. The bone density report gives densities from three sites: typically the spine, which is trabecular bone, hip which is mixed cortical and trabecular bone and the junction between the middle and distal one third or the radius, which is mostly cortical bone. In general, younger women who have post-menopausal osteoporosis lose more trabecular than cortical bone.

Competing

　Feel|Leg-Left Feel|Leg-Left
　Feel|Spine Feel|Spine
　Hammer|Ankle-Left Hammer|Ankle-Left
　Hammer|Knee-Left Hammer|Knee-Left
　Motion|Leg-Left Motion|Leg-Left
　Motion|Spine Motion|Spine
　Questions|Gait & Station Questions|Gait & Station
　View|Leg-Left View|Leg-Left
　View|Spine View|Spine
　Blood A-G|10 Alkaline Phosphatase
★Blood A-G|31 Calcium, Ca (Blood)
★X-rays|26 Lumbar Spine (X-ray) (L spine, LS spine)

On physical exam, neurologic abnormalities such as loss of sensation, muscle weakness, reflex asymmetry and a positive straight leg raising test are important to note for their value in diagnosing a radiculopathy. This would be unlikely in an osteoporotic vertebral fracture, although these signs may be observed when there is complete vertebral destruction and
encroachment of the spinal nerves. These signs may be seen in severe degenerative arthritis, spinal stenosis, or metastasis. Gait and station are important to observe but would not give convincing data to a definitive diagnosis. Similarly, the degree of spinal immobility does not make a diagnosis, but does indicate the level of impairment suffered by the patient.
The general appearance of the spine should be noted as upper and lower body segments are generally equal. It is helpful to use a tape measure to calculate the exact distance from the top of the patient1s head to the symphysis pubis of the pelvis. That distance should be equal to the area between the symphysis pubis and the bottom of the feet. A difference of more
than 2 inches suggests a shortening or deformity of the spine due to vertebral fracture, scoliosis or kyphosis.

Percussion of the spine with a vertebral fracture will result in very localized tenderness over the area of fracture. Another way to elicit this is to have the patient stand on toes and rock back smartly on the heels. This will quite often elicit pain and allow the patient to point to the exact vertebra involved.

Thorough

　Blood A-G|10 Alkaline Phosphatase
★Blood A-G|31 Calcium, Ca (Blood)
★Blood H-Z|29 Phosphorus, P (Blood)
　Blood H-Z|52 Thyroid-Stimulating-Hormone (TSH)
　Blood H-Z|25 Parathyroid Hormone (PTH) Intact
　Incomplete Diagnosis

Once osteopenia and vertebral fracture are noted on the lumbar spine film some additional studies are needed. These include serum calcium and phosphorus levels, which can be abnormal in hyperparathyroidism, osteomalacia and cancer. It might be helpful to monitor the alkaline phosphatase as it is released by osteoblasts or the cells, which form bone. An elevated alkaline phosphatase is suggestive of underlying intense bone remodeling or bone turnover. This can be
found in a vertebral fracture or in a fracture anywhere throughout the body where there is active reabsorption and repair.

Management

Required:
　MiscellaneousR06 Vitamins/minerals
　DietR17 Increase/High
　EducationR01 Diet
　EducationR02 Exercise

Recommended:
　EndocrineR02 Hormones
　NeuromuscularR03 Analgesics, narcotic

Related H&P:
★Medical History|01 Allergies [Medical History]
　Medical History|08 Gynecologic history

Related Lab:
★X-rays|09 Bone Densitometry – Dexa-Scan Hip and Lumbar Spine

Treatment is multifaceted and includes lifestyle modifications eliminating tobacco and caffeine use and decreasing or eliminating alcohol use. Increasing the use of weight bearing exercises has been of great benefit as well. Eliminating the risk of falls through proper fitting glasses and minimal use of long acting sedatives is helpful.

Pharmacological management of low bone density is proven to reduce the fracture risk in both men and women. Calcium and vitamin D are integral to bone density and maintenance. The use of Alendronate at 10g daily or Raloxifene 60mg daily has demonstrated an increase in bone mineral density and should be used in woman intolerant of estrogen or with a history of
breast cancer. Estrogen appears to reduce vertebral fractures though it’s impact on nonspinal fractures has not yet been demonstrated. Overall estrogen has demonstrated clear benefit in improvement of bone mass and fracture risk reduction, but it’s effects on the endometrium, breast and cardiovascular system should be weighed on an individual basis. Once treatment has begun progress is monitored with serial bone density studies every two-three years.

Cost / Efficiency